Successful Organ Donation After Long-Term Circulatory Support With Nonpulsatile Mechanical Support

Abstract

To the Editor: In cardiac transplantation, eligible patients are “bridged” using mechanical circulatory support (MCS) systems until a cardiac allograft becomes available. Contemporary MCS devices sustain systemic circulation by a continuous flow (CF) mechanism that generates nonphysiological, nonpulsatile flow to vital organs (1–3). We present an unconventional case of orthotopic liver transplantation (OLT) from a patient with end-stage heart failure being treated with a nonpulsatile MCS device. A 56-year-old man with end-stage nonischemic cardiomyopathywasmanagedwithaCFleftventricularassistdevice (LVAD). The LVAD (HeartMate II, Thoratec Inc., Pleasanton, CA, USA) was implanted 22 months earlier as a bridge to cardiac transplantation. MCS resulted in progressive improvement in his exercise tolerance, quality of life and end-organ function. However, the patient had been hospitalized repeatedly for refractory intravascular hemolysis related to thrombus contained within the LVAD. After failing multiple other pharmacological therapies, he was readmitted to hospital, treated with intravenous heparin and listed for emergent cardiac transplantation (UNOS status 1A). While awaiting a suitable allograft the patient became acutely unresponsive, computed tomography of the brain revealed a large left frontal intraparenchymal hemorrhage with tonsillar herniation. Neurosurgical intervention was deemed unlikely to reverse the injury, thus, the local organ procurement organization was contacted at the family’s request. Brain death was confirmed and the patient was considered a suitable donor for a patient listed for OLT. He was taken to the operating room where his liver was inspected (intraoperative biopsy revealed minimal steatosis) and subsequently procured. When the donor hepatic artery was anastomosed to the recipient’s hepatic vasculature there was minimal pulsatility following reperfusion. After a new anastomosis was fashioned and papaverine-soaked gelfoam was placed around this vessel, pulsatility improved and the arterial conduit enlarged. The remainder of the surgery was unremarkable and total ischemic time was less than